Name: (Please Print)
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Emergency Contact: (Name and Phone)
Current Medications and dosage: (not required but helpful to practitioner)
Are you currently under the care of a physician?
If yes, physician's name: (not required but helpful in an emergency)
How did you hear about us?
Have you ever received Reiki or any other type of Intuitive Healing session?
Number of previous sessions
Do you have a particular area of concern?
Are you sensitive to perfumes or fragrances?
Are you sensitive to touch?
Should be Empty:
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